26

Appendix- I

D D - M M - Y Y

(BPC or IOC or HPC)

`D D - M M - y y

1234

5 D D - M M - Y Y Y Y in (Please write Name of Newspaper)

6 /

7

First name Middle name Surname

S H R ITitle First name Middle name Surname

- email:

D D - M M - Y Y Y Y

7.77.8

8

i)ii)

iii) iv)v)

if 'No', please use the format for non-individual applicant

Pin code :

7.4

7.3

7.2

7.1

Telephone No

Name

Father’s / Husband’s Name

NO

Yes NoResident of if 'No' applicant is not eligible

Indian Citizen

7.5

7.6

Chartered Accountant

Gender

Cost Accountant

Age

Revenue District

Date of Birth

Name of Spouse, if married

Please attach copy of eligibility Certificate(s) as proof for the respective categories {SC/ST, SC/ST(GP), SC/ST(CC), OBC, OBC(GP), OBC(CC), OPEN(GP), OPEN(CC)} from the competent authorities, as mentioned in the eligibility criteria. Not Applicable for locations under 'Open' category.

Status of applicant :

Category

Name of the Location

(Enclose Application processing fee of Rs1000/ ( one thousand only) for all applicants except SC/ST candidate. Application processing fee for SC/ST candidates is Rs 500/- (Five hundred) on enclosing SC/ST certificate.)

Payable At

Educational Qualification Qualification University / Institution Degree Year of Passing

Graduation in any field

Company Secretary

Advertised on

Applicant should enclose Affidavit as per the format given in Appendix - 1

Individual YES

Marital Status

Diploma in Engineering

APPLICATION FORMAT FOR INDIVIDUAL APPLICANTS

APPLICATION FOR LPG DISTRIBUTORSHIP OF

Of f ice Code Date of receipt of applicationFor Office use Not to be filled by applicant Serial No Passport Size

Photograph with specimen

signature partially across the photograph

Please write name of Oil Company of the location

Demand Draft Number DateParticular of application fee

Drawn on (name of the bank)

In favour of ( Full name of the oil company )

DistrictState

Address

State

Age as on the date of application

Strike of f what is not applicable.

DaysMonthsYears

Male / Female

Single Married Widow Widower Divorcee

Matriculation, i.e. Xth Standard examination or equivalent from recognized Board

For SKO Dealers of OMCs:

Qualification Board/University Year of Passing

27

9

10

11

S.N

1 ` -2 ` -3 ` -4 ` -

` -Total amount in words.

Please read Item No. 11 & 12 of General Instruction before providing information on 11 & 12 below.

* Give the dimensions of the plot that will be used for proposed godown out of the total land owned. Note : Date of documents of land for Godown/Godown should be on or before the last date for submission of application as specified in the advertisement or corrigendum (if any) and the same will be verified during Field Verification.

Provide the following details of land for Showroom or showroom at the advertised location (owned or leasedfor minimum 15 years). In case land belongs to member of 'Family Unit', attach notorised affidavit as perAppendix - 2. In case land is jointly owned by the applicant/members of the family unit with any otherperson(s) or Jointly Leased in the names of the applicant/member(s) of the family unit & any otherperson(s) and the share of such land in the name of the applicant/member(s) of the Family Unit meets therequirement of land for showroom then an NOC from the joint owner(s)/joint lessee in the form of aNotarised affidavit is to be provided as per Appendix-4.

# Give the dimensions of the plot that will be used for proposed showroom out of the total land owned. Note : Date of documents of land for Showroom/Showroom should be on or before the last date for submission of application as specified in the advertisement or corrigendum (if any) and the same will be verified during Field Verification.

Dimensions of land *

Provide the following details of land for construction of LPG godown or constructed LPG godown (within 15 km from municipal/town/village limits of the advertised location in the same State) owned or leased forminmum 15 years in the name of applicant / member of 'Family Unit'. In case land belongs to member of'Family Unit', attach notorised affidavit as per Appendix - 2. In case land is jointly owned by theapplicant/members of the family unit with any other person(s) or jointly leased in the names of theapplicant/member(s) of the family unit & any other person(s) and the share of such land in the name ofthe applicant/member(s) of the Family Unit meets the requirement of land for godown then an NOC from the joint owner(s)/ joint lessee in the form of a Notarised affidavit is to be provided as per Appendix-4.

TOTAL

S. B. A/C No.Relation

with applicant

Name of account holder

(s)

AMOUNT IN SAVINGS BANK ACCOUNT in Scheduled Bank/Post Office in the name of applicant and member(s) of 'Family Unit'**. Notarised affidavit as per format given in Appendix - 2 from member(s) of 'Family Unit'** has to be submitted.

Name of Bank

Address of the location of the land for

LPG Godow n

Khasra No/Survey

No

Amount

Name(s) of the ow ner of Land / Lease holder(s)

Distance f rom location in km

Please read Item No. 9 & 10 of General Instruction before providing information on 9 & 10 below.

Note: The amount declared above in each case must be available as closing balance on the last date for submission of application as specified in the advertisement or corrigendum (if any) and the same will beverified during Field Verification.

Length in metre

Breadth in metre

Length in metre

Breadth in metre

Khasra No / Survey

No

Dimensions #

Relationship w ith applicant

Date of registration of sale deed /gift deed/ lease deed / date of mutation.

Relationship w ith applicant

Date of registration of sale deed /gif t deed/ lease deed / date of mutation.

Address of the location of the land for show room/show room

Name(s) of the ow ner of Land /show room or leaseholders

28

` -` .` .` .` .

/

14iiiiiiivvvi

15

12

I am aware that eligibility for LPG distributorship will be decided based on the information given in the application above. On verification by the Oil Company if it is found that the information given by me is incorrect/ false/ misrepresented then my candidature will stand cancelled and I will be declared ineligible for LPG Distributorship.

13

I am fully aware that I will not be appointed as LPG distributor if I am employed. I shall have to resign from the service and produce proof of acceptance of my resignation from my employer before issuance of Letter of Appointment. Failure to do so shall lead to cancellation of my selection.

Yes NoPlease strike of f what is

not applicable

I am fully aware that if I am unable to provide duly approved LPG Godown by the Office of Chief Controller of Explosives ( PESO) and / or Showroom as per the Oil Company’s standard layout , then the allotment of distributorship made to me will be cancelled.

DECLARATION BY THE APPLICANT.

(SKO dealership with Sole Proprietor only is eligible to apply)

Reference Number

with date

Name(s) of the holder

3

Initial investment

Amount

Name of Oil Company of the SKO Dealership

HPC Strike out whichever is not applicable

Type of Investment - FD/NSC/Shares/MF etc

Relation with

applicant

FIXED DEPOSIT/NSC/SHARES/MF ETC in the name of applicant and members of 'family unit'. Attach affidavit as per format given in Appendix - 2 from member(s) of 'family unit'.

Value ( Amount ) as on the date of applicationS.N

StateCategory of Dealership

Location of SKO Dealership

vii

Total amount in words.

IOC BPC

1

District

Total

2

4

Have you ever been convicted or charges have been framed by Court of Law for any criminal offence involving moral turpitude and / or economic offence (other than freedom struggle)? (If yes you are not eligible to apply.)

Note : (1) The above declared investments should be available on the last date for submission ofapplication as specified in the advertisement or corrigendum (if any) and the same will beverified during Field Verification.(2) The value (Amount) shown above should be as on Date of Application.

Additional Information to be furnished by existing SKO (Kerosene) Dealers of OMCsName of SKO Dealership

Please attach copy of month-wise allocation for preceding 12 months from the month of advertisementfor this LPG Distributorship, issued by the allocating authority of the State Government / Divisional /Territory / Regional Office of the concerned Oil Marketing Company.

Constitution of Dealership Proprietorship

I also confirm that, if selected, I will present all the supporting documents in original in respect of the information given by me in this application and failure to present these documents in original will result in cancellation of selection.

Partnershi Society Company Strike out w hichever is not applicable

I am also aware that I cannot draw any salary / perks /emoluments (other than the pension received) from the State/Central Government and I have to forgo these benefits at the time of appointment as LPG Distributor. Failure to comply to this condition will lead to cancellation of my selection.

viii Average monthly SKO allocation during the preceding 12 months prior to monthof advertisement for this LPG Distributorship.

Average KL/month

(SKO dealership with average SKO monthly allocation of 75 KL or more are not eligible to apply)

29

d d - m m - y y y y(Name in block letters)

List of Enclosures12 Demand Draft No_______________________ dated ________________34 Notarised Affidavit in original as per the format in Appendix 25 Notarised Affidavit in original for Joint ownership of land as per the format in Appendix 46 For OBC candidates, Notarised Affidavit in original as per the format in Appendix 3c

That, if selected, I undertake that I will be depositing an interest free Security deposit as per the policy of the Corporation.

I have read the terms and conditions applicable for the LPG Distributorship mentioned in the advertisement/ Brochure and confirm that I fulfill the eligibility criteria for the LPG Distributorship I have applied for in this application.

I, _________________________________________________________daughter of /son of/ wife of Shri__________________________________ hereby confirm that the information given above is true and correct. Any wrong information /misrepresentation/ suppression of facts will make me ineligible for this LPG distributorship.

Place :

Date :

Signature of applicant

Name of applicant

Copies of Eligibility Certificate(s) for the category applied.

I am aware that if married, my spouse will be co-owner i.e. 50% partner of LPG distributorship with me and I am not permitted to enter into partnership with anyone other than my spouse.

I am fully aware that I have to personally manage the operation of LPG Distributorship.

Undertaking

Total number of pages of the application including attachments

Notarised Affidavit in original as per the format in Appendix 1

I am aware that if selected I have to deposit 10% of the applicable security deposit before the FVC is carried out. In case if it is found that the information given by me is incorrect/ false/ misrepresented then my candidature will liable to be cancelled along with forfeiture of the amount deposited before FVC.

30

(NOTORISED AFFIDAVIT)

1

2 d d / m m / y y y y

y y y y

y y y y

y y y y

y y y y

y y y y

5

6

7

8

9

10

That I passed Graduation examination from recognised University / Institution in the year* and / or

and / or

That I have passed & completed Cost Accountant examination in the year *

That I have passed & completed Engineeering Diploma examination in the year *

and / or

and / or

That if any information/declaration given by me in my application or in any document submitted by me insupport of application for the award of the LPG Distributorship or in this affidavit shall be found to be untrueor incorrect or false, the Indian Oil Corporation*/ Bharat Petroleum Corporation* /Hindustan PetroleumCorporation* would be within its rights to withdraw the letter of intent / terminate the distributorship (ifalready appointed) and that I would have no claim, whatsoever, against the Corporation for such withdrawal/ termination.

That I have never been convicted nor charges have ever been framed against me by any Court of Law forany criminal offences involving moral turpitude and/or economic offences (other than freedom struggle).

That I hereby confirm that I was never a signatory to dealership/distributorship agreement of any OilCompany, which was terminated for proven malpractices and / or for violations of provisions of theMarketing Discipline Guidelines.

(c) I am aware that if I am selected for the LPG distributorship, I will have to surrender my SKODealership before being appointed as LPG Distributor by IOC/BPC/HPC .

OR

That I am unmarried. That neither I, nor my Father, Mother, unmarried brother(s), unmarried sister(s) havedealership/distributorship or hold Letter of Intent for Retail Outlet or SKO-LDO dealership or LPGdistributorship or RGGLV of any Oil Company.

ORThat I am divorcee . That neither I, nor unmarried son(s)/unmarried daughter(s) (whose custody is given tome) have dealership/ distributorship or hold letter of Intent for Retail Outlet or SKO-LDO dealership or LPGdistributorship or RGGLV of any Oil Company:

That I am of sound physical and mental health.

(a) That I am the sole proprietor of SKO dealership of _________ (OMC name) in the Name & Style of____________________ at _______________ (location) operating below an average allocation of 75 KL ofSKO per month during the immediate preceding 12 months prior to the month of advertisement for the LPGDistributorship.

(b) That I have not been penalized for violation of Marketing Discipline Guidelines within last 5 yearspreceding the date of advertisement and/or there are no proceedings pending against my Dealership underMarketing Discipline Guidelines, Dealership Agreement, Kerosene Control Order or ESMA.

For Applicants applying under the category of SKO dealers :

That I am married and name of my spouse is __________________. That neither I nor my spouse,unmarried son(s)/unmarried daughter(s) have dealership/ distributorship or hold letter of Intent for RetailOutlet or SKO-LDO dealership or LPG distributorship or RGGLV of any Oil Company:

ORThat I am widow/widower . That neither I nor my unmarried son(s)/unmarried daughter(s) have dealership/distributorship or hold letter of Intent for Retail Outlet or SKO-LDO dealership or LPG distributorship orRGGLV of any Oil Company:

That I hereby confirm that none of my family members (as defined in clause 6.1 (iv) of the Brochure) areemployees of Oil Marketing Companies.

4

3

That I have passed & completed the course of Chartered Accountant in the year*

That I have passed & completed the course of Company Seceratary in the year*

(in words_______________________________)

I,____________________________________ son/daughter/wife of ________________________________ Age_____ years residing at ___________________________ do hereby solemnly affirm and say as under :

Appendix - 1(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)

That I am an Indian Citizen and residing in India.

That my date of birth is

31

* Strike off whatever is not applicable.

Solemnly affirmed and declared before me

Signature and Seal of Signature of person making affidavitMagistrate/Judge/Notary public

I hereby verify that what has been stated above is true and correct to the best of my knowledge andnothing material has been concealed therefrom.

This ___________day of ________________

(Name in block letters)

32

(NOTORISED AFFIDAVIT)

Relationship with applicant.

(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)Appendix - 2

3 That in case he/she is selected for LPG distributorship I have no objection for construction of godown / showroom on the land specified in item no 9 & 10 in my name.

1 That I am unmarried and my father*/mother*/unmarried brother* / unmarried sister*(Mr/Ms)__________________________________(name) has applied for LPG distributorship ofIOC*/BPC*/HPC* at _______________(location) under '__________' category against the advertisementmade in __________________news paper dated__________________ .

(To be given by the family member as defined in eligibility criteria other than applicant)

I _____________________________________ Son/wife of______________________________________ Age______years resident of _____________________do hereby solemnly affirm and say as under:-

Name of Deponent

ORThat I am married and my unmarried son*/ unmarried daughter*/wife*/husband*(Mr/Ms)__________________________________(name) has applied for LPG distributorship ofIOC*/BPC*/HPC* at _______________(location) under '__________' category against the advertisementmade in __________________news paper dated__________________ .

I hereby verify that what has been stated above is true and correct to the best of my knowledge, and nothing has been concealed therefrom

Solemnly affirmed and declared before me

* Strike off whichever is not applicable.

This_________________________ day of _______________________________

Signature and Seal of Magistrate/Judge/Notary publicSignature

2 That in case he/she is selected for LPG distributorship I will provide financial assistance to the extent ofamount which is mentioned at Item no.11 & 12 under my name in the application submitted by(Mr/Ms)___________________________.for LPG distributorship of IOC*/BPC*/HPC* at____________________________ .

33

Appendix - 3a

Note : The terms “Ordinarily reside(s)” used here will have the same meaning as in Section-20 of the Representation of the People Act, 1950.

# Officers competent to issue Caste / Tribe certificates.

i. District Magistrate / Additional District Magistrate / Collector / Deputy Commissioner / Additional Deputy Commissioner / Deputy Collector, 1st Class Stipendiary Magistrate / City Magistrate *** Sub-Divisional Magistrate / Taluka Magistrate / Executive Magistrate / Extra Assistant Commissioner.

*** (Not below the rank of 1st Class Stipendiary Magistrate)

ii. Chief Presidency Magistrate / Additional Chief Presidency Magistrate, Presidency Magistrate.

iii. Revenue Officers not below the rank of Tehsildar.

State / Union Territory*

Place : ____________ Signature : ______________

The Constitution (Andaman & Nicobar Islands) Scheduled Tribes Order, 1956*

The Constitution (Dadra & Nagar Haveli) Scheduled Castes Order, 1962*

The Constitution (Scheduled Tribes) (Uttar Pradesh) Order, 1967*

The Constitution (Nagaland) Scheduled Tribes Order, 1970*

v. Administrative / Secretary to Administrator / Development Officer (Lakshadweep).

Date : ____________ Designation : ______________ (with seal of office)

STANDARD FORMAT FOR SC/ST CATEGORY CERTIFICATE

Note: A candidate who claims to belong to one of the Scheduled Castes / Scheduled Tribes should submit insupport of his / her claim, a certificate in original, with a copy thereof in the form given below, issued at any time by a competent authority # notified by the Government of India, of the district in which his parents (or survivingparents) ordinarily reside who has been designated by the State Government concerned as competent to issuesuch a certificate. If both his parents are dead, the officer signing the certificate should be of the District in whichthe candidate himself ordinarily resides otherwise than for the purpose of his own education. In case of any doubtabout the genuineness of the certificate, the same may be got verified through the concerned District Magistrate /Deputy Commissioner.

The form of the certificate to be produced by Scheduled Castes / Scheduled Tribes candidates.

This is to certify that Shri / Smt. / Kum* ______________ son / daughter* of ________________ of village / town *______________ in District / Division* _______ of the State / Union / Territory* of ___________ belongs to the________Caste / Tribes and his / her religion is ___________ which is recognised as a Scheduled Castes /Scheduled Tribes under the Scheduled Castes / Scheduled Tribes lists (modification) order 1956* read with theBombay Re-organisation Act, 1960 and the Punjab Reorganisation Act 1956*.

The Constitution (Jammu & Kashmir) Scheduled Castes Order, 1956*

* Please delete the words which are not applicable.

iv. Sub-divisional officer of the area where the candidate and / or his family normally resides.

The Constitution (Pondicherry) Scheduled Castes Order, 1964*

34

Appendix - 3b

Sl.No.

(with seal of office)

STANDARD FORMAT FOR OBC CATEGORY CERTIFICATE

Dt. of Gazette Notification Concerned State / UT

Shri / Smt. / Kum*. __________________________________________________ and / or his/her family ordinarilyreside(s) in village/town* __________________________________of _________________________________ District/ Division* of the State/Union Territory* of _________________________________.

This is also to certify that he/she does not belong to the persons/sections (Creamy Layer) mentioned in Column 3 of theSchedule to the Government of India, Department of Personnel & Training O.M. No. 36012/22/93-Estt.(SCT) dated08/09/93 which is modified vide Government of India, Department of Personnel & Training OM No. 36033/3/2004-Estt(Res) dated 14.10.2008.

Place : __________________________ Signature : Date : ___________________________ Designation :

State / Union Territory*______________________

* Please delete the words, which are not applicable

Note: A candidate who claims to belong to one of the Other Backward Classes should submit in support of his /her claim, a certificate in original, with a copy thereof in the form given below, issued by a competent authoritynotified by the Government of India.

The form of the certificate to be produced by “Other Backward Classes” candidates.

This is to certify that Shri / Smt. / Kum.* ________________________________________________ son/daughter*of __________________________________________________________ ofVillage/Town*__________________________ District/Division*________________________of the State/UnionTerritory* of __________________________________ belongs tothe_________________________________Community which is recognized as a backward class under:

Resolution No.

NOTE: (a) The term ‘Ordinarily’ used here will have the same meaning as in Section 20 of the Representation of thePeople Act, 1950.

(b) The authorities competent to issue Caste Certificates for Other Backward Classes are given below: (i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional DeputyCommissioner/Deputy Collector / Ist Class Stipendiary Magistrate /Sub-Divisional Magistrate / TalukaMagistrate / Executive Magistrate / Extra Assistant Commissioner (not below the rank of Ist ClassStipendiary Magistrate).

(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.

(iii) Revenue Officer not below the rank of Tehsildar and

(iv) Sub-Divisional Officer of the area where the candidate and / or his/her family resides.

(c) The last date for submission of application mentioned in the notice of advertisement or corrigendum (if any) willbe treated as the date of reckoning for OBC status of the candidate and also for determining that the candidatedoes not fall in the creamy layer. The candidate should furnish the relevant OBC Certificate in the format prescribed above issued by the competent authority.

35

Appendix - 3c

(Signature of the Candidate)

Place : __________________________

Date : ___________________________

Declaration/undertaking as a Notarized affidavit - for OBC Candidates (TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)

I, ____________________________________________ son/daughter of Shri__________________________________ resident of village/town/city ____________________________________in the District __________________________ of State / Union Territory of________________________________________ hereby declare that I belong to the__________________________________________ community which is recognized as a backward class by theGovernment of India for the purpose of reservation in services as per orders contained in Department of Personneland Training Office Memorandum No.36012/22/93- Estt.(SCT), dated 8/9/1993. It is also declared that I do notbelong to persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the above referred OfficeMemorandum, dated 8/9/1993, which is modified vide Department of Personnel and Training Office MemorandumNo. OM No. 36033/3/2004-Estt(Res) dated 14.10.2008.

Declaration/undertaking not signed by Candidate will be rejected.

False declaration will render the applicant liable for rejection of application/candidature at any time.

36

Appendix - 3d

Signature/Thumb impression of the patient

Countersigned by the Medical Superintendent/CMO/Head of Hospital (with seal)

Recent Attested PhotographShowing the disability affixed here.

This is to certify that Shri/Smt./Kum.----------------------wife/daughter/son of Shri ____________________________________________ Age ______________old male/female, Registration No. _____________________ is acase of physically disabled/visual disabled/speech & hearing disabled and has ____________ %(____________________) permanent (physical impairment/visual impairment/speech & hearing impairment) inrelation to his/her ___________________________________________________.

Note: -1. This condition is progressive/non-progressive/likely to improve/not likely to improve. *2. Re-assessment is not recommended/is recommended after a period of ____________________ months/years. *Strike out which is not applicable.

STANDARD FORMAT FOR PH CATEGORY CERTIFICATE

Sd/- Sd/- Sd/-(DOCTOR) (DOCTOR) (DOCTOR) Seal Seal Seal

NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE

Certificate No.Date

CERTIFICATE FOR THE PERSONS WITH DISABILITIES

37

Appendix - 3e

I

II

III

IV

V

Attested Signatures of applicant

Place : ____________ Signature :Name :

Date : ____________ Designation :

Office Seal :

Eligibility Certificate for Paramilitary/Police/Government/PSU Personnel Category

# This is to certify that Mr/Ms ________ who was working in this office as ________ had passed away on (date) _______ at (Place)___________. Mr/Ms ________ has been awarded ( name of gallantry award)________in recognition of the supreme scarifice made while__________________,

Mr/Ms ( name of applicant) _________________ ( relationship ___________ ) was dependent on Mr/Ms ____________ as per our records.

OR# This is to certify that Mr /Mrs ________________________________who was working in this office as __________ had passed away on (date) ________________ while in action at (Place)______________

Mr/Ms ( name of applicant) _________________ ( relationship ___________ ) was dependent on Mr/Ms ____________ as per our records.

OR# This is to certify that Mr/Ms ( name of applicant)__________________________ was working in our organization ________ and has been disabled on ( date) -----------while performing duties at (place)________.

OR# This is to certify that Mr /Mrs ________________________________who was working in this office as ______ had passed away on (date) ________________ while on duty at (Place)______________

Mr/Ms ( name of applicant) _________________ ( relationship ___________ ) was dependent on Mr/Ms ____________ as per our records.

OR# This is to certify that Mr/Ms _________ was working in our organization ________ and has been disabled in peace on ( date) __________ due to attributable causes.

# Delete if not applicable.

Certificate is to be given by Head of the Office or an Officer not below the rank of Under Secretary to the Government on Official Letter-Head of the Organization / Government Office issuing the Certificate.

Reference No.Date

STANDARD FORMAT FOR PARAMILITARY/POLICE/GOVERNMENT/PSU PERSONNEL CATEGORY

38

Appendix - 4

1

* Land for Godown :

* Land for Showroom :

2

3

This_________________________ day of ______________(month)________________(year)

Signature and Seal of SignatureMagistrate/Judge/Notary Public Name of Deponent

Relationship of the member of

Family Unit with Applicant

(Not Applicable for Third Party)

Date of registration of Sale Deed / Gift Deed /

Lease Deed / Date of

Mutation

* Strike out whichever is not applicable

Khasra no./ Gatta

No./Survey No.

Dimension of Land offered as per

Demarcated Plan (____metres X ______metres)

Notarized Affidavit for offer of land from applicant/member of the family unit and third party – All thejoint owners/Joint Lessee of the land (except the applicant) have to submit this affidavit individuallyincluding the member of the family unit.

(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)

I _____________________________________ Son/Daughter/wife of________________________________age______years resident of _____________________do hereby solemnly affirm and say as under:-

That I, Shri/Smt _____________________, own a piece of land jointly or Jointly Leased, bearing Gatta/Khasra/Survey No. _____________ at ___________________ (village/town), Taluka/Tehsil __________,Dist _____________________ and measuring area of _____ sq. mts. (Dimensions ______metres X______metres) in the State of _____________ as per the following details :

Date of registration of Sale Deed / Gift Deed /

Lease Deed / Date of

Mutation

Khasra no./ Gatta

No./Survey No.

Dimension of Land offered as per

Demarcated Plan (____metres X ______metres)

Names of the Joint owner(s)/Joint Lessee

Relationship of the member of

Family Unit with Applicant

(Not Applicable for Third Party)

That in case he/she is selected for LPG Distributorship, I confirm that I do not have any objection for theconstruction of the LPG godown and/or showroom (as required by OMC) at the above mentionedlocation, as per the demarcation on the site plan enclosed.

I hereby verify that what has been stated above is true and correct to the best of my knowledge, and nothing hasbeen concealed there from.

I also confirm that I have not offered this piece of land to any other person for the above purpose.

That Shri/Smt ______________________ has applied for LPG Distributorship of IOC*/BPC*/HPC* at_______________(location) under '__________' category against the advertisement appeared in__________________news paper dated__________________ .

Names of the Joint owner(s)/Joint Lessee

Solemnly affirmed and declared before me.

39

Item No

1

2

3

4

5

6

7

8

9

Proof of Date of Birth like School LeavingCertificate/Birth Certificate/Passport / PAN Card.

Original certificate for each qualification

Documents pertaining to land / Godown in thename of applicant or member of 'family unit'Registered Sale Deed/ Gift Deed / Lease Deed(15yrs minimum )/Mutation and government recordetc.

The Date of the documents have to be on or beforethe last date for submission of application asmentioned in the advertisement or corrigendum, ifany. In case land is in the name of member of 'familyunit', consent from the family member in form ofNotorized Affidavit (Appendix 2) is required to beattached with the application.

In case land is jointly owned by theapplicant/member of the Family Unit with any otherperson(s) or jointly leased in the name of theapplicant/member of the Family Unit & any otherperson(s) and the share of such land in thename of the applicant/member of the Family Unitmeets the requirement of land for godown then anNOC in the form of an affidavit from the jointowner(s)/joint lessee is to be provided as perAppendix-4.

'Family Unit' is defined below in Important Note.

Personal Details are to be filled and Notorised Affidavitas per format given in Appendix -1 to be submitted

Education : - Information in chronological order

Details of the plot of Land for godown or ready madegodown which meets the following requirement:-

The plot of land should be of adequate size (within 15km from municipal/town/village limits of the locationoffered in the same State) for construction of godownfor storage of minimum 8000 Kg of LPG in cylinders orready LPG cylinder storage godown. As per GasCylinder Rules 2004, the floor area of the storage shedfor storing 8000 kg LPG in cylinders should be 80 sqmetres. The length of the storage shed should not bemore than 1.5 times of width of storage shed. Thereshould be clear minimum safety distance of 7 metersbetween storage shed and the boundary wall/ fencing.

A plot of land with minimum dimension of 26.15 metreby 27 metre is adequate. It should be freelyaccessible through all weather motorable approachroad (public road or private road connecting to thepublic road). It should also be plain, in one contiguousplot, free from live overhead power transmission ortelephone lines. Canals / Drainage / Nallahs should notbe passing through the plot. The land for constructionof LPG godown should also meet the norms of variousstatutory bodies such as PWD/Highway authorities/Town and Country Planning Department etc.

Write the name of the location for which application ismade as per advertisement.Write the name of the district of the location for whichapplication is made as per advertisement.Write the name of the State of the location for whichapplication is made as per advertisement.Write the name of the category of the location as perthe advertisement

Instructions Supporting Documents to be provided by applicant at the time of verification.

Eligibility certificates issued by the competentauthorities as applicable. Caste validity certificateas applicable. For example, if the category oflocation is SC (CC), the applicant has to provideeligibility certificate for both SC & CC categories.Similarly, in case of OBC, the applicant has toprovide eligibility certificate of OBC along withDeclaration/Undertaking (Notarized affidavit) forbelonging to both the OBC & non-creamy layerstatus.

Write the date and name of the news paper in which advertisement has appeared for the location mentioned in item 1. Tick the status of Applicant: whether applicant is individual Yes or No. If No, use the application format of Non-Individual Applicant

General Instructions to the candidates applying for LPG Distributorship.

40

10

11.0

13

Details of the Land for Showroom / Showroom whichmeets the following requirements:-

Own a suitable shop of minimum size 3 meters by 4.5meter in dimension or a plot of land for construction ofshop of minimum size 3 meters by 4.5 meter at theadvertised location or locality as specified in theadvertisement. It should be easily accessible togeneral public through a suitable approach road.

Amount in the Saving Account in Scheduled bank /Post Office in the name of self & the member(s) of the"Family Unit" should be available as closing balanceas on the last date for submisson of application asmentioned in the advertisement or corrigendum (if any)and only such closing balance will be considered.

Amount maintained in the joint account withmember(s) outside the "Family Unit" should not bementioned and will not be considered.

Investment in Bonds/NSC in the name of self andmember of the "Family unit" - value (amount) as ondate of application. Fixed Deposit/Term Deposit/PPF in ScheduledBank/Post Office/listed Companies/Governmentorganisation/PSU in the name of self and member ofthe Family Unit - value (amount) as on date ofapplication. The investments as declared in the application must be available as on last date of submission of applicationas specified in the advertisement or corrigendum (ifany), for verification.

Attach Notarized Affidavit as per format given inAppendix - 2, if applicable.

Amount maintained in the joint account withmember(s) outside the "Family Unit" should not bementioned and will not be considered.

Investments in listed Mutual Funds/listed companyshares/ULIP based on the NAV on the date ofapplication.

Amount of money which applicant can get on surrender of Insurance policy.Conviction or charges have been framed by Court ofLaw for any criminal offence involving moral turpitudeand / or economic offence (other than freedomstruggle).

Documents pertaining to land / showroom in thename of applicant or member of 'family unit'. Sameas mentioned in the item 9 above.

Savings Bank Accounts Statement/ Pass Bookfrom which the amount mentioned in theapplication to be available as closing balance onthe last date for submission of application asmentioned in the advertisement or corrigendum (ifany) can be verified.

All supporting documents based on which theamount has been declared as on the date ofapplication in Point No. 12 needs to be madeavailable.

Declared Value (amount) as on the date ofapplication for the investment instruments ascertified by the Bank/Post Office or the concernedfinancial institution/issuing organisation.

In case fixed deposit(s)/PPF/TermDeposit/Bonds/NSCs etc have matured betweenthe date of application and the last date forsubmission of application as mentioned in theadvertisement or corrigendum (if any), then theapplicant should present any other instrument asmentioned in Item 11 & 12 of the application as aproof of having re-invested the declared amount.Date of such investment should be on or before thelast date for submission of application as given inthe advertisement or corrigendum (if any).

Value on the date of application as certified by theGovernment Approved Valuer or the concernedfinancial institution/ certified by CharteredAccountant.Certificate from the Insurance Company

Notorised Affidavit as per format given in Appendix -1 to be submitted

12.0

41

14

S.No123456

7

891011

Additional Information to be furnished by SKO(Kerosene) dealers for item No.i to viii.

Notarised Affidavit as per format given in Appendix -1 to be submitted.

Month-wise Allocation letter(s) for preceding 12months from the month of advertisement for thisLPG Distributorship, issued by the allocatingauthority of the State Government orDivisional/Territory/ Regional office of theconcerned OMC to be submitted.

Copy of the SKO Dealership Agreement with theconcerned OMC.

Check list for Applicants

*******

Undertaking at the end of application duly signed with name, date and place.

The Application is complete in all respect.

All pages of apllication are numbered and signed.

Notorised Affidavit in original as per format given in Appendix 1 attached.

Total Number of pages

Notorised Affidavit in original - Declaration/Undertaking as appicable for OBC applicants as per Appendix - 3c.

Copy(ies) of eligibility certificate(s) for the category attached as applicablePhotograph pasted and signature across photograph

Document / Activity to be checked Check box

Important Notes : 1. 'Family Unit’** of a married applicant, shall consist of self, applicant's spouse and unmarriedson(s)/daughter(s) and ‘Family Unit’ of a unmarried applicant, shall consist of self, applicant's parentsand applicant's unmarried brother(s) / sister(s) for the purpose of this entire application.

2. Applicant must provide all information sought against various items mentioned in the Applicationform. If selected, at the time of verification, the applicant will have to provide documents in original insupport of the information furnished in the application. Failure to present these documents in originalat the time of verification will result in cancellation of selection along with forfeiture of the amountdeposited by the selected candidate before the FVC.

3. In case, applicant requires extra space for providing details on any point, the details can be providedby adding extra rows or by adding extra sheets. However, details should be given in the same formatas mentioned in that particular point.

DD attached - verify amount, drawn in favour of concerned company and payable at

Notorised Affidavit in original as per Annexure 4 as applicableNotorised Affidavit in original as per Annexure 2 as applicable